National Ambulatory Medical Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
National Ambulatory Medical Care Survey 2011 Parnel - NAMCS 1	Form and Instruction	Modified	Available
2011 Pretest NAMCS Patient Record	Form	New	Available
2011 Pretest Asthma Supplement	Form	New	Available
2011 Pretest Physician Induction Interview	Form	New	Available
Physician Workflow Survey - EHR/no EHR Supplement 2	Form	New	Available
Physician Workflow Survey - EHR/no EHR Supplement 2	Form	New	Available
2012 Asthma Supplement	Form	New	Available
NAMCS - EMR Supplement 2011	Form	Modified	Available
Form 5 NAMCS-CCS Cervical Cancer Screening Supplement (Line 5)	Form	Removed	Available
Pulling and Refiling of Patient Record	Form	Modified	Repair queued
NAMCS 2011 Patient Record Folio	Form	Modified	Available
Community Health Center Induction Interview 2011	Form	Modified	Available
FINAL NAMCS 2011-2013 OMB SS-B_1201.doc	Supporting Statement B	Uploaded 2011-02-14	Available
Att U Federal Register Public Comments.doc	Supplementary Document	Uploaded 2011-02-14	Repair queued
Att Q FINAL EHR Workflow Letters.doc	Supplementary Document	Uploaded 2011-02-14	Available
Att P Letters used in the study 2009 Mail Survey.doc	Supplementary Document	Uploaded 2011-02-14	Available
Att N Endorsing Agencies.pdf	Supplementary Document	Uploaded 2011-02-14	Available
Att M NAMCS Intro Letters and Mod Insert.doc	Supplementary Document	Uploaded 2011-02-14	Available
Att L Pulling and Re-filing.doc	Supplementary Document	Uploaded 2011-02-14	Available
Att K ERB Letter.pdf	Supplementary Document	Uploaded 2011-02-14	Available
Att J 2011-2013 NAMCS Consultants.doc	Supplementary Document	Uploaded 2011-02-14	Available
Att I Federal Register.pdf	Supplementary Document	Uploaded 2011-02-14	Available
Att A Public Health Service Act.doc	Supplementary Document	Uploaded 2011-02-14	Available
Att O FINAL namcs-1 cc.pdf	Supplementary Document	Uploaded 2011-02-14	Available
Att C 2012 NAMCS CAM questions.doc	Supplementary Document	Uploaded 2011-02-14	Available
FINAL NAMCS 2011-2013 OMB SS-A_1201.doc	Supporting Statement A	Uploaded 2011-02-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43612	NAMCS-1 Physician Induction Interview (Line 1)	Form and Instruction	Modified	National Ambulatory Medical Care Survey 2011 Parnel - NAMCS 1
196407	2011 Pretest NAMCS Patient Record Form (line 10)	Form	New	2011 Pretest NAMCS Patient Record
196406	2011 Pretest Asthma Supplement (line 9)	Form	New	2011 Pretest Asthma Supplement
196405	2011 Pretest Physician Induction Interview (line 8)	Form	New	2011 Pretest Physician Induction Interview
196404	Physician Workflow Survey (line 7)	Form	New	Physician Workflow Survey - EHR/no EHR Supplement 2
196404	Physician Workflow Survey (line 7)	Form	New	Physician Workflow Survey - EHR/no EHR Supplement 2
196403	2012 Asthma Supplement (line 5)	Form	New	2012 Asthma Supplement
189597	NAMCS EMR/EHR Mail Survey (Line 6)	Form	Modified	NAMCS - EMR Supplement 2011
181892	NAMCS-CCS Cervical Cancer Screening Supplement (Line 5)	Form	Removed	NAMCS-CCS Cervical Cancer Screening Supplement (Line 5)
181891	Pulling and re-filing Patient Record form (Line 4)	Form	Modified	Pulling and Refiling of Patient Record
181890	NAMCS-30 Patient Record form (Line 3)	Form	Modified	NAMCS 2011 Patient Record Folio
181889	NAMCS-201 Community Health Center Induction Interview (Line 2)	Form	Modified	Community Health Center Induction Interview 2011

ICR Details

OMB Control No: 0920-0234	ICR Reference No: 201102-0920-016
Status: Historical Active	Previous ICR Reference No: 201010-0920-006
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Ambulatory Medical Care Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/28/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/25/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2013	36 Months From Approved	02/28/2013
Responses	71,827	0	51,469
Time Burden (Hours)	11,502	0	7,372
Cost Burden (Dollars)	0	0	0

---

Abstract: Data collected from office-based physicians, and community health center providers, concerning patient visits are aggregated to national statistics. This request will permit NAMCS in 2011 to collect electronic medical record (EMR) that has been approved in 2008. Numerous changes are requested for the 2011-2013 period, including: 1)increasing the sample size by 1,500 physicians, 2)introudce a provider-based mail survey to assess physician workflow before and after EMR implementation, 3) an asthma supplement for 2012, 4) questions on NAMCS induction form about complementary and alternative medicine for 2012, and 5) sample of 300 physicians to for pretests.

---

Authorizing Statute(s): PL: Pub.L. 111 - 5 1512 Name of Law: American Recovery and Reinvestment Act of 2009
   US Code: 42 USC 242K Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 39947	07/13/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 7858	02/11/2011
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
2011 Pretest Asthma Supplement (line 9)	none	2011 Pretest Asthma Supplement
2011 Pretest NAMCS Patient Record Form (line 10)	none	2011 Pretest NAMCS Patient Record
2011 Pretest Physician Induction Interview (line 8)	none	2011 Pretest Physician Induction Interview
2012 Asthma Supplement (line 5)	none	2012 Asthma Supplement
NAMCS EMR/EHR Mail Survey (Line 6)	none	NAMCS - EMR Supplement 2011
NAMCS-1 Physician Induction Interview (Line 1)	none	National Ambulatory Medical Care Survey 2011 Parnel - NAMCS 1
NAMCS-201 Community Health Center Induction Interview (Line 2)	none	Community Health Center Induction Interview 2011
NAMCS-30 Patient Record form (Line 3)	none	NAMCS 2011 Patient Record Folio
NAMCS-CCS Cervical Cancer Screening Supplement (Line 5)	5	NAMCS-CCS Cervical Cancer Screening Supplement (Line 5)
Physician Workflow Survey (line 7)	none, none	Physician Workflow Survey - EHR/no EHR Supplement 2 ,   Physician Workflow Survey - EHR/no EHR Supplement 2
Pulling and re-filing Patient Record form (Line 4)	none	Pulling and Refiling of Patient Record

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	71,827	51,469	0	20,358	0	0
Annual Time Burden (Hours)	11,502	7,372	0	4,130	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The estimated burden hours are higher in this revision due to more planned activities for the 2011-2013 survey period. One IC was removed for this survey period.

---

Annual Cost to Federal Government: $5,385,970

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/25/2011

---